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Chronic Constipation in Adults: Contemporary Perspectives and Clinical Challenges. 2: Conservative, Behavioural, Medical and Surgical Treatment

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Chronic Constipation in Adults: Contemporary Perspectives and Clinical Challenges. 2: Conservative, Behavioural, Medical and Surgical Treatment Received: 23 July 2020 | Revised: 5 December 2020 | Accepted: 13 December 2020 DOI: 10.1111/nmo.14070 REVIEW Chronic constipation in adults: Contemporary perspectives and clinical challenges. 2: Conservative, behavioural, medical and surgical treatment Maura Corsetti1,2 | Steven Brown3 | Giuseppe Chiarioni4,5 | Eirini Dimidi6 | Thomas Dudding7 | Anton Emmanuel8 | Mark Fox9,10 | Alexander C. Ford11,12 | Pasquale Giordano13 | Ugo Grossi14 | Michelle Henderson15 | Charles H. Knowles16 | P. Ronan O’Connell17 | Eamonn M. M. Quigley18 | Magnus Simren5,19 | Robin Spiller1,2 | Kevin Whelan6 | William E. Whitehead5 | Andrew B. Williams20 | S. Mark Scott16 1NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK 2School of Medicine, University of Nottingham and Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK 3Department of Surgery, University of Sheffield, Sheffield, UK 4Division of Gastroenterology, University of Verona, AOUI Verona, Verona, Italy 5Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA 6Department of Nutritional Sciences, King’s College London, London, UK 7University of Southampton NHS Trust, Southampton, UK 8GI Physiology Unit, UCL & UCLH, London, UK 9Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland 10Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland 11Leeds Institute of Medical Research at St. James’s, University of Leeds, Leeds, UK 12Leeds Gastroenterology Institute, St. James’s University Hospital, Leeds, UK 13Department of Colorectal Surgery, Barts health NHS Trust, London, UK 14Tertiary Referral Pelvic Floor and Incontinence Centre, Regional Hospital Treviso, University of Padua, Padua, Italy 15Durham Bowel Dysfunction Service, Old Trust Headquarters, University Hospital of North Durham, Durham, UK 16National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK 17Centre for Colorectal Disease, St Vincent’s University Hospital, Dublin, Ireland 18Lynda K and David M Center for Gastrointestinal Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA 19Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 20Guy's and St Thomas, NHS Foundation Trust, London, UK Abbreviations: 5-HT, 5-hydroxytryptamine; ACE, anterograde continence enema; CC, chronic constipation; CI, confidence interval; CSBM, complete spontaneous bowel movements; FC, functional constipation; FMT, fecal microbiota transplantation; GC-C, guanylate cyclase-C; hERG, human ether-a-go-go-related gene; IBAT, ileal bile acid transporter; IBS, irritable bowel syndrome; IBS-C, irritable bowel syndrome with constipation; MDT, multidisciplinary team; NHE3, sodium-hydrogen exchanger 3; RCT, randomized controlled trials; SGLT1, sodium-glucose linked transporter 1; SMD, standardized mean difference; SNM, sacral neuromodulation; SRMA, systematic review and meta-analysis; STARR, stapled transanal rectal resection; TAI, transanal irrigation. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2020 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd. Neurogastroenterology & Motility. 2021;00:e14070. wileyonlinelibrary.com/journal/nmo | 1 of 15 https://doi.org/10.1111/nmo.14070 2 of 15 | CORSETTI et AL. Correspondence Maura Corsetti, Nottingham Digestive Abstract Diseases Biomedical Research Centre, Background: Chronic constipation is a prevalent disorder that affects quality of life of Queens Medical Centre – D Floor, West Block, Derby Road, Nottingham, NG7 patients and consumes resources in healthcare systems worldwide. In clinical practice, 2UH, UK. it is still considered a challenge as clinicians frequently are unsure as to which treat- Email: [email protected] ments to use and when. Over a decade ago, a Neurogastroenterology and Motility journal supplement devoted to the investigation and management of constipation was published (Neurogastroenterol Motil 2009;21(Suppl 2):1). In October 2018, the 3rd London Masterclass, entitled “Contemporary management of constipation” was held. The faculty members of this symposium were invited to write two reviews to present a collective synthesis of talks presented and discussions held during this meeting. The first review addresses epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Purpose: The present is the second of these reviews, providing contemporary per- spectives and clinical challenges regarding behavioral, conservative, medical, and sur- gical treatments for patients presenting with constipation. It includes a management algorithm to guide clinical practice. KEYWORDS algorithm, constipation, IBS-C, treatment 1 | INTRODUCTION 2 | BEHAVIORAL AND CONSERVATIVE INTERVENTIONS Chronic constipation (CC) remains a clinical challenge, with out- comes to a variety of interventions (behavioral, conservative, medi- 2.1 | Behavioral management cal, and surgical) that are frequently suboptimal. Over a decade ago, a Neurogastroenterology and Motility journal supplement devoted Behavioral modification is a commonly recommended, but inconsist- to the investigation and management of constipation was pub- ently applied, first-line treatment for patients with CC. It generally lished, disseminating all themes covered during a preceding two- includes patient education about the nature of their condition, advice day meeting held in London [1]. In October 2018, the 3rd London regarding lifestyle modification, toilet habit training, and instruction Masterclass, entitled “Contemporary management of constipation” on defecation dynamics. The extent to which behavioral modifica- was held, again over 2 days, and again boasting a world-renowned tion helps individual patients is difficult to quantify, perhaps inevita- faculty. By way of dissemination, two side-by-side review articles bly given the nature of such a composite intervention; accordingly, have been produced, which represent a collective synthesis of talks clinical trials of the individual components that constitute behavioral presented and discussions held during this meeting. The authors modification therapy do not exist, though they are described below were all invited faculty members. These reviews provide not only to help the reader understand the patient approach required. an update on topics addressed in the previous journal supplement, Establishing rapport between patient and professional is a key but also a state-of-the-art overview of the clinical management of component to any educational initiative. Empathic reassurance is this prevalent and often difficult-to-treat condition. Areas for fu- also key to helping the patient recognize that they will be supported ture research are additionally highlighted. The first review article along their journey to improve compliance. addresses epidemiology, diagnosis, clinical associations, patho- physiology, and investigation. This “sister” review addresses the contemporary perspectives and clinical challenges regarding be- 2.2 | Lifestyle advice havioral, conservative, medical, and surgical treatments in patients presenting with constipation. It includes a management algorithm The average adult in the UK eats 60% (18 g) of the recommended to guide clinical practice. As constipation can present as functional daily fiber intake [2]. Irregular eating habits and low-fiber diets are constipation (FC) or irritable bowel syndrome with constipation considered risk factors for constipation [3,4]. (IBS-C), where available, evidence for both is presented. When not Patients with CC are often told to increase dietary fiber; guide- specified, data should be assumed to relate to patients with CC and lines suggest supplementation with 25 g to 30 g per day [5, 6], but not to a specific subtype. it is important to understand the mechanism of action since there CORSETTI et AL. | 3 of 15 are some significant side effects, which may be reduced by gradual Thus, it appears that fibers that alleviate constipation act on both titration. Insoluble fibers, such as wheat bran, increase small bowel the small and large intestine to increase stool water, accelerate tran- water content [7], and accelerate small bowel [8] and colonic transit sit, and facilitate defecation. [9], thereby increasing stool frequency [10, 11]. Bran contains sub- Although a diet low in fermentable carbohydrates (FODMAPs) stantial amounts of fermentable fiber, which may worsen some as- has been shown to improve symptoms of irritable bowel syndrome sociated symptoms in CC, including abdominal pain, flatulence, and in several randomized controlled trials [27, 28], there is a lack of con- bloating [12]. Soluble fiber, such as psyllium, increases small bowel vincing evidence on its effectiveness in IBS-C specifically, and its and colonic water content, but not colonic gas, with an increase in impact in FC has not been investigated.
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